Kuakini Geriatric Care, Inc

F-F656 Develop/Implement Comprehensive Care Plan

1) On 01/05/25 at 11:56 AM an interview was conducted with Resident R89 in her room. Resident R89 was observed sitting in her wheelchair with a nasal cannula which was hooked up to the oxygen (O2) in the wall. Inquired of Resident R89 if

the oxygen was on and she confirmed it was on and at 2 Liters per minute (LPM) at all times for her shortness of breath due to her diagnosis of chronic obstructive pulmonary disease (COPD). Inquired of resident when does staff change the nasal cannula and she stated staff changes it out when she asks them to, when it gets dirty or wet inside the tubing. During the interview surveyor and Resident R89 did not observe any sticker with the date the O2 tubing was implemented.

Review of Resident R89's Electronic Health Record (EHR) found she was admitted to the facility on [DATE REDACTED] and her diagnoses include, but are not limited to, chronic obstructive pulmonary disease with (acute) exacerbation (persistent respiratory disease with respiratory symptoms significantly worsening); acute respiratory failure with hypoxia (not enough oxygen in the blood); acute respiratory failure with hypercapnia (too much carbon dioxide in the blood); emphysema (air sacs of the lungs are damaged), unspecified; and pulmonary fibrosis (scarring and thickening of the tissue around and between the air sacs in the lungs), unspecified.

Review of Resident R89's Admission Minimum Data Set (MDS) with an assessment reference date of 11/05/24 found

she had a Brief Interview for Mental Status (BIMS) with a score of 15 out of 15 identifying her as cognitively intact. Review of Resident R89's physician orders found an order for Supplemental O2 (oxygen) 2-4L/min by nasal cannula with humidifier continuous to keep sats > (greater than) 90% every shift for COPD.

On 01/06/25 requested and received oxygen use policy from facility Administrator.

On 01/08/25 reviewed facility policy Respiratory Delivery Devices dated 01/24, Purpose: To set guidelines for

the use of respiratory delivery devices in the facility which include nasal cannula, non-breather [sic.] mask, oxymizer pendant and bland aerosol administration. Scope: All qualified and trained Personal staff. Policy: Qualified and trained personal will utilize, treat, and monitor use of these respiratory delivery devices. Procedure: A. Nasal Cannula (1/4 - 6 LPM) . 3. Change nasal cannula weekly and PRN soiled.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 13 125026 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 125026 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kuakini Geriatric Care, Inc 347 North Kuakini Street Honolulu, HI 96817

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 On 01/08/25 at 08:47 AM interviewed Registered Nurse (RN)33 outside of Resident R89's room and inquired who changes the nasal cannula tubing and when is it done. RN33 stated night shift usually changes the tubing Level of Harm - Minimal harm or and sterile saline for residents on O2. They usually change it on Fridays. At this time inquired of Resident R89 about potential for actual harm her nasal cannula and she stated staff did change out her tubing on Sunday 01/05/25 when she asked them about it, after our first interview before lunch. Resident R89 stated the sticker came off and she was able to put it on Residents Affected - Few her bedside table. Sticker was dated 01/05/25 and timed at 1400 (02:00 PM).

On 01/08/25 at 12:04 PM an interview was conducted with the Director of Nursing (DON). Inquired who changes the nasal cannula for those residents receiving O2. She confirmed the nasal cannula is switched out weekly by staff and as needed when it gets dirty. Inquired of DON if staff label the new tubing with dates and DON confirmed the nasal cannula tubing and bottle of sterile water should have had dates on them.

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2) On 01/05/25 at 02:10 PM observation in Resident R19's room. Resident R19 was lying in his bed with Oxygen (O2) at 3 Liters per minute (LPM) via trachea collar and connected to an aerosol bottle with a blue tube. There was no label on the blue tubing with a date to indicate when it was changed.

Quarterly Minimum Data Set (MDS) with an assessment date of 07/19/24 was reviewed on 01/06/25. Resident R19 is

a [AGE] year-old male with a diagnosis that includes respiratory failure requiring Oxygen therapy and Tracheostomy care.

Treatment Administration Record (January 2025) reviewed on 01/06/25. Apply trachea collar daily.

On 01/08/25 at 11:30 AM, interviewed the Director of Nursing (DON) in her office with the Administrator. The surveyor asked the DON how often the respiratory tubing is changed and by whom. The DON discussed that

the tubing is changed on night shift every Friday and that the tubing should be labeled to indicate that it was changed.

Facility Respiratory Delivery Devices policy 01/2024 was reviewed on 01/06/25. C. T-Piece/Trach Collar with Aerosol (21-100% Fio2, Set Flow 6-10 LPM) .6. Change nebulizer, tracheostomy collar, and tubing set up daily and as needed (PRN).

3) Observation on 01/05/25 at 02:45 PM in Resident R216's room who is on droplet precautions. Resident R216 was lying in bed with his eyes closed and observed to have a deep productive cough. He was wearing a nasal cannula (NC) for O2 delivery. Observation of the O2 meter on the wall behind the head of the bed was not registering (in the off position). Observed the O2 tubing was not labeled with a date when the O2 tubing was changed.

Observation and interview with Registered Nurse (RN) 25 in Resident R216's room on 01/05/25 at 03:30 PM. The surveyor asked RN25 what the concentration of O2 is ordered for Resident R216. RN 25 looked at the meter and said it's not on, but it's supposed to be at 2 L. RN25 turned the dial on the O2 meter until it reached 2 L. The surveyor asked RN25 when was the tubing was changed, by who and how often. She replied, its changed weekly by the Nursing staff, then looked closer at the tubing and said, there should be a label to note the date it was last changed, but there isn't one.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 13 125026 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 125026 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kuakini Geriatric Care, Inc 347 North Kuakini Street Honolulu, HI 96817

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Physician orders dated 01/04/25 reviewed on 01/05/25. Noted droplet precautions for the respiratory syncytial virus (RSV) positive (+). Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 13 125026 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 125026 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kuakini Geriatric Care, Inc 347 North Kuakini Street Honolulu, HI 96817

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37954 safety Based on observation and interview the facility failed to assure kitchen staff using the dishwasher waited for Residents Affected - Many the water temperature to raise to 180 degrees Fahrenheit (F) or more during the final rinse cycle before processing the dishes from the conveyor belt, placing them on the storage racks of clean dishes, failing to assure dishware and silverware were heat sanitized. This deficient practice puts all residents and staff, who eat their meals at the facility, at risk for foodborne illness.

The State Agency (SA) identified an Immediate Jeopardy (IJ) at S483.60 (

F-F812) on 01/05/25 at 08:44 AM.

Findings Include:

On 01/05/25 at 08:43 AM an initial tour was conducted with Food Services Supervisor (FSS)1. During initial tour of the kitchen found the kitchen uses a dishwasher with high temperatures to sanitize their dishware and silverware. Review of facility log for the dishwasher stated Standards: Wash - 140-160 degrees F and Final Rinse - 180-190 degrees F. If temperature is above or below range, please inform the supervisor. Logs of temperatures written in for 01/01/25 - 01/04/25 were all within the standard temperatures.

Observed dishwasher at 08:44 AM with dishes loaded on the conveyor belt moving through the dishwasher and kitchen staff unloading the dishes onto a rack. During this time, the dishwasher temperature was checked by surveyor and the final rinse was at 172 degrees F. Inquired of the FSS1 what the final rinse temperature was at, and she stated 172.

Inquired with the Food Service Worker 1 who also confirmed the temperature was at 172 degrees F. Inquired with Food Service Worker (FSW) 2 what the final rinse has to be at for the dishes to be sanitized and she did not respond, FSW2 continued to unload the dishes that had gone through the dishwasher.

Inquired with FSS1 what the final rinse has to be at, and she told staff to stop what they were doing. She stated the final rinse has to be 180 degrees or more. Inquired with FSS1 if the dishwasher uses a chemical sanitizer to clean the dishes and she said it is done by heat. FSS1 showed surveyor where the dishwasher detergent was dispensed from that leads to the dishwasher and also showed the Temp Rinse All Temperature Drying Agent.

On 01/05/24 at 10:00 AM returned to the kitchen to meet with the Administrator to discuss findings about the dishwasher use. Reviewed dishwasher detergent with Administrator who confirmed the Micro-Pak detergent by microTECH concentrates is not a sanitizer and he also confirmed the Temp Rinse All Temperature Drying Agent is not a sanitizer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 13 125026 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 125026 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kuakini Geriatric Care, Inc 347 North Kuakini Street Honolulu, HI 96817

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 On 01/05/25 at 10:35 AM, the facility Administrator was notified in writing of the IJ and provided with the IJ template. Administrator signed the template to attest receipt of the notice. The facility failed to follow the Level of Harm - Immediate proper sanitizing practices for the dishes and silverware to prevent the outbreak of foodborne illnesses as jeopardy to resident health or evidenced by final rinse temperatures of the water in the High Temperature Dishwasher (using heat safety sanitization) that were below the temperatures recommended for safety by the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code (https://www.fda. Residents Affected - Many gov/media/110822/download). Widespread serious harm is likely to all residents using facility dishware and/or utensils due to risk of transmission of enteral pathogens related to improper sanitization.

On 01/05/25 at 01:04 PM requested kitchen use of dishwasher machine policy from Administrator which he provided.

Review of policy titled Procedure for washing dishes by the use of a machine, Effective date: 01/10/18 states Purpose: To properly wash and sanitize dishware and silverware for its aesthetic value and to prevent the spread of harmful germs to patients, residents and staff.

Scope: Food service workers

Policy: All dishes, dishware and silverware shall be washed after each use. Dish machine [sic.] wash temperature should be 140-160 degrees F and final rinse temperature should be 180 degrees F and above.

Procedure: .

5. In the event of any of the following conditions, the dishwashing procedures shall be stopped immediately.

The food service worker shall inform the supervisor who shall call the Plant Operations department or the service representative. The supervisor shall direct the staff to use the dish machine [sic.] at Hale Pulama [NAME]

b. Final rinse temperature is below 180 degrees - call Plant Operations.

On 01/05/25 at 11:55 AM the facility presented an acceptable plan for removal of the immediate jeopardy.

On 01/06/25 at 04:00 PM, the SA finalized onsite verification that the IJ Removal Plan, provided by the facility and approved by the SA, had been implemented. Immediately the facility utilized one time use disposable plastic utensils and paper tableware (plates, cups and trays) till IJ was lifted. The facility was able to provide inservice training with their kitchen staff on proper use of the dishwasher which included coverage of final rinse temperature to be reached when cleaning dishes in the dishwasher prior to processing dishes and placing them on the clean rack. Kitchen staff were reminded to notify the kitchen supervisor if the wash and rinse temperatures are not met when using the dishwasher. Facility consulted with vendor for sanitizer that could be used with heat sanitizing dishwasher but this was not something the vendor offers. Vendor informed Kitchen Manager the sanitizer would break down with the heat.

Facility monitored residents for 72 hours for signs and symptoms of infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 13 125026 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 125026 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kuakini Geriatric Care, Inc 347 North Kuakini Street Honolulu, HI 96817

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51868 potential for actual harm Based on observation, interview, and record review, the facility failed to implement the facility's infection Residents Affected - Few prevention and control measures for three out of twenty-three resident sampled.

a. Resident (R)23 and (R)38 who were on isolation precautions did not have signage outside of their rooms at the door.

b. The facility failed to assure staff to use proper personal protective equipment (PPE) when delivering a meal to a Resident (R)72 who was on droplet precautions. This deficient practice placed everyone at risk for developing preventable infections and other adverse health complications.

Findings include:

1) Resident R23 was a [AGE] year-old resident admitted to the facility for long-term care. Diagnosis included but not limited to Methicillin Resistant Staphylococcus Aureus, an infection that is resistant to many antibiotics, and had an order for contact isolation effective 08/03/24.

On 01/05/25 at 10:57 AM, observed no signage was posted outside Resident R23's room stating that he was on transmission-based precautions (TBP) instructing everyone to follow contact precaution and check with the nurse before entering the room.

On 01/05/25 at 11:02 AM, an interview was conducted with Patient Care Coordinator (PCC)3 and confirmed that Resident R23 is on TBP, and that signage should have been placed outside his door to alert everyone. When asked if facility is supposed to place the signage, PCC3 confirmed, Yes, that should be placed outside the resident's door.

On 01/07/25 at 10:21 AM, an interview was conducted with Director of Nursing (DON) in her office and confirmed that a sign should always be placed outside resident's room if they're on isolation precautions to alert staff, family, and visitors to prevent spread of infections.

Review of facility's policy on 01/07/25, Infection Control - Section 3.0 Body Substance Precautions stated, . a STOP sign is placed on the door to alert personnel and visitors to Check with the nurse before entering

37954

2) Cross reference to 656 Develop/ Implement Comprehensive Care Plan. Review of Resident R38's electronic medical record found he returned to the facility and was readmitted on [DATE REDACTED]. Resident R38 had received antibiotics for a urinary tract infection (UTI) intravenously three times a day for Sepsis due to acute pyelonephritis and ESBL/UTI until 01/03/25 which was documented as completed on 01/03/25. Review of Resident R38's Care Plan (CP) revealed staff are to utilize enhanced barrier precautions to care for resident related to history of ESBL. Interventions listed on Resident R38's CP included Cart set up outside of patient's room and stocked with appropriate Personal protective Equipment (PPE) and trash can inside the room for discarding used PPE items or soiled items. Place an enhanced barrier isolation sign on resident room door.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 125026 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 125026 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kuakini Geriatric Care, Inc 347 North Kuakini Street Honolulu, HI 96817

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 01/07/25 at 12:58 PM an observation was made outside of Resident R38's room along with a concurrent interview with Certified Nurse Aide (CNA) 25. Surveyor observed inside and outside of Resident R38's room and saw there was Level of Harm - Minimal harm or no signage or PPE cart posted outside of resident's room and no discard bin inside Resident R38's room for used potential for actual harm PPEs. Inquired of CNA25 where the EBP sign and PPE cart was and CNA25 stated he is not on EBP, she confirmed there was no sign and cart of PPEs outside of Resident R38's room. Residents Affected - Few

On 01/08/25 at 10:49 AM interview with the Director of Nursing (DON) was conducted. Inquired about Resident R38's CP which she confirmed has a CP for EBP due to his recent UTI with ESBL. She confirmed staff should be using PPEs and sign should be up outside the room door and cart should have been outside of the room with PPEs.

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3) On 01/05/25 at 11:50 AM, observed Certified Nurse Aide (CNA)32 in Resident R72's room delivering lunch. There was signage on the entrance to Resident R72's room documenting the resident was on Droplet Precautions. However, CNA32 only wore a surgical mask. Inquired with CNA32 as to why Resident R72 was on droplet precautions. CNA32 reported Resident R72 was on droplet precaution due to testing positive for Respiratory Syncytial Virus (RSV).

On 01/08/25 at 10:30 AM, conducted an interview with the DON. Informed the DON of my observations and inquired what PPEs should staff wear while delivering a resident's meal who is on droplet precautions. DON confirmed staff should have been wearing a face-shield, gown, an approved mask, and gloves.

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FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 125026